Additional file

Community-based Approaches: What Works and Why?

Community-based interventions have proven to be effective in multiple contexts

for the control and prevention of diseases of poverty [1-2]. However there is a

major gap to guide best practice and policy options in the context of global

change [3]. Without taking stock of already validated approaches and learning

from them, it will be exceedingly difficult to imagine future pathways under the

complexity of global change scenarios. Adaptation relies on innovation to grapple

with a changing world, which will require working from, and modifying, existing

tools.

Here we summarize the results of the systematic review on community-based

interventions for 7 vector-borne diseases, relating past approaches to the context

of future global change.1 We develop a panoptic perspective on the types of

approaches that are available and have been tested and evaluated. Furthermore,

we ask: what works, why, in what context and for whom? Seven major types of

community-based activities were identified, explored and analyzed. We situate

these approaches within the broader context of socio-ecological systems theory

and concepts of vulnerability and adaptation. The applicability of these

approaches for contexts of global change is discussed, with specific examples

provided from a country-level. This review informed the analysis and discussion

in the attached paper, “Addressing Vulnerability, Building Resilience: Community-

based Adaptation to Vector-Borne Diseases in the Context of Global Change.”

1. Methodology of the Review

We aimed to identify key community-based interventions and approaches that

could help reduce vulnerability for 7 major VBDs in the context of global change.

1 It is important to note that taking such a “disease specific approach” does not mean that we are neglecting the important issue of co-infection, solely emphasizing so-called “vertical approaches” or overlooking the importance of integrated strategies – far from it.

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Due to the scarcity of scholarly literature that directly reports on global change,

community-based adaptation and VBDs, there was a need to methodologically

innovate and extrapolate. Hence the review involved multiple stages of data

gathering, analysis and conceptual synthesis.

A search on both PubMed and Google Scholar databases found very little

literature that documented community-based interventions to reduce global

change risks for VBDs. Furthermore, very few scholarly articles were found that

reported community-based studies on climate change and VBDs, aside from

modeling efforts and some entomological studies.

Table 2: Results of the Literature Review

Disease Number of articles identified

Number excluded

Number screened

Number included in qualitative synthesis

Number added to the database

Chagas disease

212 95 117 29 2

Dengue 295 248 47 55 8

HAT 163 126 37 25 8

Leishmaniasis 184 48 136 23 5

Malaria 2057 755 1302 419 9

RVF 22 15 7 5 2

Schistosomiasis 394 110 284 81 6

Total 3327 1397 1930 637 39

For these reasons, a systematic literature search was done to first synthesize

major findings from existing community-based approaches to the 7 VBDs. The

goal was to use this literature to identify the range of community-based

mechanisms and pathways relevant to each VBD under social, environmental

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and climate change conditions. This search reviewed articles that described the

monitoring and/or evaluation, either through qualitative or quantitative social

research methods, of community-based prevention or control interventions for

the 7 selected VBDs. Secondary searches were also done using Google Scholar

to identify related articles, reviews and grey literature, such as project reports,

that were then incorporated into the reviews as relevant. These sources were

included if they provided additional conceptual insight, not all of which were

disease specific.

For the systematic review, PubMed was used (see Table 2 above). This involved

the following key search terms: [DISEASE X] and MONITORING or

EVALUATION or QUALITATIVE or QUANTITATIVE or ETHNOGRAPHY or

PARTICIPATORY and LOCAL or SOCIAL or PARTICIPATORY or

INTERVENTION. Only articles published in English between 1990 and 2015

were included. In total, the search found 3,327 articles and included 673 articles

in the qualitative synthesis. An additional 39 articles were included in the

database – these were either cited in other studies or retrieved through our

secondary literature search. Articles were excluded if they were not in English,

not on the selected diseases, a review article or did not report the results of

research activities that explored a community-based prevention or control

intervention.

A total of 66% and 13% of the included articles were on malaria and

schistosomiasis respectively. Not all articles that were included in the qualitative

synthesis were included in this final report. A more selective approach was used,

which relied on selecting articles that provided the greatest descriptive and

analytical detail on vulnerability, the process of implementation, community

responses and overall effectiveness factors. Using these selected articles, we

followed a “realist review” approach, as outlined by Pawson et al. [4]. This

focused on “providing an explanatory analysis aimed at discerning what works for

whom, in what circumstances, in what respect and how.”

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2. Major Findings

2.1. Vector Surveillance and Risk Mapping

One of the major needs in addressing future VBD scenarios relates to the

uncertainties about the distribution and consequence of global change on vectors

and pathogens. Surveillance systems remain the main source of information for

policymakers and frontline health managers to assist with decision-making,

resource allocation and response. Monitoring changes in atypical environmental

conditions, such as rainfall and flooding in arid areas, and engaging in timely

community-based vector control activities, have been shown to prevent

epidemics of malaria and RVF [5]. To be effective, geographical information

systems and surveillance must account for tracking and anticipating current and

future conditions. This requires epidemiological and entomological evidence and

investment in surveillance systems and modeling [6]. One tool that may prove to

be particularly useful in this regard is the strengthening of existing local

surveillance systems at the district level, particularly the use of existing Health

and Demographic Surveillance Systems (HDSSs) that provide longitudinal data

in established sites globally [7]. Such systems could guide ongoing adaptation

and resilience efforts and the implementation of intervention packages.

Box 1: Hunting Triatomine Bugs in Guatemala

A number of initiatives have sought to involve communities in the surveillance and control of triatomine bugs in Latin America, the vectors of Chagas disease (Abad-Franch et al. 2011; Weeks et al. 2014). In Guatemala, a major Japan International Cooperation Agency (JICA) project (2000-2008) contributed to the interruption of R. prolixus transmission and significant reductions in T. dimidiate. This was achieved through surveillance, insecticide spraying and education [8].

But with decreasing funds for surveillance, a community-based bug-hunting campaign was piloted at scale. Using a participatory and intersectoral approach, ‘Chagas week’ encouraged community members to search their homes for Triatominae vectors. A range of stakeholders were involved (schoolchildren, community leaders, NGOs and community health volunteers) in outreach activities. The department of health showed strong ownership in the initiative,

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and also provided funds. Promotional flyers, bug reporting forms, lottery tickets and plastic bags for capturing the bugs were distributed, with the slogan: Busque la chinche picuda y gane su premio (Look for kissing bugs and win your prize).

The term “prize” was important, as bugs were exchanged with project officers for raffle tickets, which was especially popular in schools. The campaign was highly effective at improving vector surveillance, with a near 6-fold increase in the number of Triatominae vectors detected over more passive surveillance. This allowed for risk maps to be generated and for insecticide application to be used more effectively. It also raised political attention to the consequences of Chagas disease and the need to invest in sustained vector control.

From Yoshioka [9]

Additionally, despite the potential, community-based surveillance has not been

widely used for most VBDs. Tsetse traps, triatomine “hunts”, and tracking and

managing malaria cases are three notable exceptions. A study in Cambodia

piloted the use of unsalaried village malaria workers to monitor potential

artemisinin resistance in Plasmodium falciparum treated patients 72-hours

after initiating treatment. The study found significant variation in the system

depending on the level of supervision and training of village workers and health

clinic staff [10]. These findings are repeated in the literature on tsetse traps,

which highlight that communities are willing and able to deploy traps, monitor

catches, maintain traps and liaison with public health and entomological

authorities in the context of sufficient technical and financial support [11]. A study

in Uganda explored community perceptions of traps in a control project, albeit the

study is applicable to a surveillance context [12]. In villages where traps were

familiar, people had very positive attitudes towards them, but where they had

never been seen before they provoked fear and anxiety, related to witchcraft and

“ghosts from the river.” While this highlights the importance of early engagement

with communities and the need to consider local perceptions, surveillance

incentives, didactic learning and a multi-sectoral approach are also all important

components (see Box 1).

2.2. Housing and the Domestic Environment

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Vector control includes a major focus on domestic spaces where human-vector-

environment interactions take place. This ranges from bednets that keep

sleeping quarters safe from nighttime mosquitoes, to the crevices in houses

where triatomine bugs lay their eggs, to the water containers and recycling

material where Aedes aegypt reproduce and spread dengue, CHIK and ZIKV.

Numerous examples exist of simple housing improvements and changes in the

urban environment that can reduce these diseases.

A large amount of research has been conducted on bednets, from local

perceptions, usage, maintenance, efficacy and sustainable community-based

distribution systems. Net care programs have been widely implemented using

social and behavior change communication (SBCC) techniques. Studies have

highlighted increased knowledge and attitudes to care and repair and modest

increases to net durability– a study in Uganda showed a roughly 30% increase in

net care, albeit with limitations for overall net condition [13]. Socio-economic

status is often highlighted as a key influence on net condition, questioning how

inequities reinforce an inability for poor households to care for their nets over

time [14]. From the perspective of local people, nets can also catch fish, which

can solve another problem for them: food insecurity.

A major issue for bednet success also relates to shifting sleeping patterns in

response to notions of comfort (to avoid heat), livelihood patterns and nighttime

socio-cultural and economic activities [15]. A study in Rwanda found that men

were less likely to sleep under a bednet, even when they were available [16].

Perceptions of malaria risk are also important. Indifference can be rooted in a

lack of fear of malaria infection, posing problems for elimination efforts [17]. An

anthropological study on the implementation of long-lasting insecticidal nets and

hammocks distributed to migratory Ra-glai ethnic minorities in Vietnam (who

spend significant time in the forest during the malarial season) found that half of

the local population did not use them in their forest plot huts, where they used

slash and burn farming. This study recommended that programs target the

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agricultural fields where migrants seasonally reside, and not only permanent

settlements that are more easily accessible to public health outreach teams [18].

In this sense, promoting community resilience involves maintaining and

sustaining the goal of universal coverage by better targeting high-risk populations

in remote regions. Despite a massive global campaign, insecticide-treated

bednet (ITN) coverage is still not universal; an estimated 49% of the population

at risk of malaria globally had access to ITNs in 2013, up from 4% in 2004.

Questions about sustainable funding, as well as emerging resistance,

evolutionary pressure on mosquito feeding behavior and possible long-term

toxicity of pyrethroid insecticides, raise major concerns.

But not all vector control is about bednets or malaria. Community-based housing

improvement interventions, for example, have been found to be very effective for

Chagas disease, including a longstanding program in Venezuela [19]. Source

reduction campaigns for Aedes mosquitoes have also been tested in multiple

settings, especially where water usage and storage pattern are responsible for a

large amount of Ae. aegypti larval habitats [20]. A frequent refrain from

community-based research is that people lack knowledge on Aedes habitats and

the importance of water containers; dengue is often associated with ‘dirty water’

and ‘worms’ [21].

Box 2: A Community-based Aedes Source Reduction Campaign in Ecuador

In recent years, dengue has replaced malaria as a major cause of febrile illness in parts of Ecuador. Mitchell-Foster et al. [22] conducted a randomized control trial of a participatory source reduction campaign in an urban area of Ecuador, where dengue epidemics are becoming more frequent due to climatic variation. The intervention was done in 10 intervention clusters, and consisted of an integrated dengue prevention approach using elementary school-based education and community-wide clean patio and safe container campaigns using neighborhood groups. This was found to have significantly reduced the pupa per person index, as compared to control clusters.

The intervention included practical skill development and application using a 6-

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week “Clean Patio and Safe Container” strategy, which mobilized students to remove discarded and unused containers from patios and cover water containers in peri-domestic spaces. The impact of this project was more significant in areas with long-standing community-based political action aimed at revitalizing government-community relations and infrastructure, such as community groups that had already mobilized for the installation and improvement of sewers, roads, lighting in public spaces, a children’s play-ground, increased police presence and improved garbage collection. The intervention also helped foster improvements in solid waste removal and public works reduction of standing water.

From Mitchell-Foster et al. [22]

Without a vaccine or effective treatment, and with significant gaps in the

management of vertical dengue control programs [23], a number of randomized

control trial cluster studies, using a participatory approach, have recently been

done, with support from TDR, in Asia and Latin America, areas where global

changes are shifting dengue dynamics. These have ranged from using

schoolchildren and a backyard cleanup campaign in Brazil [24], integrated vector

management and stakeholder engagement in Myanmar [25], women’s self-help

groups and tailor-made water container covers using local carpenters in India

[26], garbage collection services in Uruguay [27] and insecticide-treated net

windows and water containers in Colombia [28]. All of these interventions, most

of which are demonstration studies, reveal the need to maintain appropriate

technology, motivate existing political support and address community

mobilization (See Box 2). They show that participation was often lacking when no

local community organizations existed, or where social instability and a lack of

community cohesion were present, such as in migrant slum communities. While

some have since been scaled-up across a much larger area, with the intention to

understand how source reduction can impact dengue cases, publications are few

and far between. A unique study in Cuba on the scale-up process showed that

important elements of a participatory approach were left out due to insufficient

dissemination of the approach to government decision-makers, misinterpretation

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of participatory principles, and a resistance to organizational change at the

management level [29].

2.3. Modifying Natural Environments

Vectors are influenced by land use patterns, agriculture, water and human

settlement. While insecticide application remains a mainstay of current control

strategies, environmental modification has played a major historical role in vector

control efforts [30], and still holds great potential today (see Box 3). Modifying

river boundaries, draining swamps, clearing vegetation and modifying human

habitation have all been used for malaria, schistosomiasis and sleeping sickness

control. As efforts are scaled-up to eliminate VBDs, such as malaria,

environmental modification has become more emphasized in the face of drug

resistance, insecticide-resistant vectors and a shifting climate [31].

Box 3: Cleaning Drains to Prevent Malaria in Dar es SalaamCommunity-based management of ecosystems offers a viable alternative to chemically-based vector control, but is under-utilized and under-studied. Between 2005 and 2007, researchers in Tanzania used community sensitization and mobilization to clean and manage two large drains (4 km long) as part of a pilot study. Drain cleaning activities were planned in consultation with community members and the city, municipal and ward leaders. Most of the hired workforce were local people, who cleaned the drains and did minor repairs. Community sensitization was done using seminars, mass meetings and house-to-house visits. The intervention reduced Anopheline breeding sites and cases of malaria. After 18-months, one of the drains was still been regularly maintained and cleaned, while the other had fallen into disrepair. The level of sensitization and community perceptions about the efficacy of the approach in reducing malaria influenced the management of the drains.

From Castro et al. [32]

Agricultural systems are also known to influence vector dynamics, and are

effective routes for initiating community-based adaptations. A study in Kenya

found that agricultural practices, such as dumping cassava tuber peelings, trench

digging, irrigation and fishponds significantly favored mosquito breeding [33]. In

Côte d'Ivoire, De Plaen et al. [34] showed how the intensification of irrigated rice

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cultivation lead to a reduction in the capacity of women to manage malaria

disease episodes due to time constrains and increased labor demands. An

intervention study in Morocco used participatory rural appraisal (PRA) to facilitate

community analysis of schistosomiasis control options. Without outside support,

a local irrigation committee repeatedly cleaned and removed vegetation from

canals, which was found to be a very effective, low-cost and sustainable snail

and schistosome control approach [35]. A local doctor was found to have played

a key role in motivating the village committee, showing the important role of local

champions.

People are willing to actively engage in their own effort to manage local

environments (i.e. by managing stagnant water) but it is clear that communities

require assistance to identify the most effective strategies to use, to facilitate

collective action and to maintain activities over time [36].

2.4. Animal-based Interventions

Animal-based interventions involve engaging in the human norms, values and

economics that govern our use of animals. One pathway for VBDs control

involves the strengthening of livestock systems within a broader strategy for rural

development. For example, the use of zooprophylaxis for the prevention of

malaria in areas where livestock provide a protective layer, such as for

Anopheles arabiensis in irrigated villages in Africa and Anopheles stephensi in India [37]. In other circumstances, however, closer contact with animals can

increase chances for VBD infection, as with livestock slaughter practices in the

transmission of RVF and dog-keeping practices for leishmaniasis. In Brazil,

insecticide-treated collars have been used for leishmaniasis prevention. Mass

dog culling has also been implemented, although the effectiveness of this

approach has been widely questioned and has been resisted by local

communities who find it inappropriate due to cultural values of dog ownership

and companionship [38].

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An integrated control strategy has been very effective in China for zoonotic

schistosomiasis, which includes engaging farmers in the task of restricting cattle,

who transmit schistosomes in their feces, from accessing snail-infested

grasslands. This has involved using village committees to help introduce a

system of mechanized agriculture to replace the need for large numbers of bulls,

although the functioning of this system has not always worked as expected due

to farmer interests and landscape factors [39]. Implementation of animal-based

interventions also requires appreciating the ways that animals are valued, how

livestock management is influenced by land patterns and climate, and the role of

livestock in the rural economy. There may be opportunities to foster management

changes that decrease natural resource challenges associated with increased

VBD risk, and also help with broader livelihood improvements (see Box 4).

Box 4: Strengthening Veterinary Services to Prevent Sleeping Sickness in Uganda

In northern Uganda, an epidemic of sleeping sickness accompanied the end of war and conflict in the early 2000s. A public-private partnership was established to prevent human infection by implementing a series of mass cattle treatments using prophylactic drugs. For sustainability, a network of veterinary drug shops and community-based animal health workers were used to sell insecticides to farmers. This helped prevent animal and human trypanosomiasis as well as tick-borne cattle diseases. The veterinary network included community outreach and training following a social entrepreneurship model. While successful in some respects, community perceptions of drug and product efficacy, spray patterns, socio-economic trends and the incentives of community-based workers to treat cattle, generated a tension between business and sleeping sickness prevention. Other products only effective on ticks and not tsetse predominated in the market, and were often preferred by farmers due to lower up-front costs. Efforts to organize village-wide spray routines were not effective in the context of a post-conflict economy and a culture suspicious of state-led interventions. The lack of effective policy to treat cattle at livestock markets before they are moved to new districts continues to spread the human diseases to new areas.

From Bardosh [40]

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2.5. Water, Sanitation and Hygiene (WASH)

The control of VBDs is frequently considered separate to the behavioral and

infrastructural dimensions of water, sanitation and hygiene (WASH), despite a

number of vector-borne infections having a major WASH dimension [41].

Sanitation and hygiene issues involve transferring infections from blood and

feces to people, all of which have strong socio-cultural dynamics. Poorly

constructed and maintained latrines, an essential component of WASH, can

contribute to the breeding of culex mosquitoes, and so latrine maintenance can

play a role in vector control.

Schistosomiasis is perhaps the best studied VBD in terms of community

involvement with WASH. Transmitted through urination and defecation in

waterways inhabited by the snail vector, the disease predominately infects young

children and fishermen due to livelihood and recreational practices around rivers

and streams [42]. Behavioral research has shown that water use and contact are

complex, influenced by daily mobility patterns, livelihoods, geography and

gendered use of space [43-44]. The staple of current schistosomiasis control is

mass drug administration (MDA) of praziquantel; however research shows that

reinfection is common and that drug resistance may be developing in certain

contexts [45]. The current practice of deworming with no intervention to prevent

re-worming amounts to installing an indefinite dependence on drugs for control

that is not sustainable. An alternative, ‘water-based approach’ has been

promoted, albeit mostly from the margins of mainstream policy [46]. The

magnitude and pattern of investment required in WASH to address

schistosomiasis, and other infectious diseases simultaneously, is difficult to

gauge.

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Box 5: A Participatory WASH Approach to Prevent Schistosomiasis

Schistosomiasis is widely endemic in Tanzania, with distributions predicted to change with climate change and other social and environmental shifts. Current control regimes focus almost exclusively on MDA, with little attention given to intensified health education and WASH. A participatory hygiene and sanitation transformation (PHAST) intervention was piloted in one hyper-endemic village in Ukerewe district. This approach facilitated a community group to develop an health action plan to improve WASH. A trainer-of-trainers workshop was used to organize a cadre of local volunteers to conduct classroom-based and village-based learning. This increased community knowledge and reduced water contact behavior in infected rivers, despite overall variations by sex, age-group and time of day. Children below the age of 15 years were most receptive to the PHAST intervention, while women did not change their water contact behaviors at all. After one-year, the intervention was found to not only have reduced overall risks but also decreased the wealth gap between households in the village by increasing household assets, housing and land ownership patterns. Community members attributed these changes to the participatory approach used and the secondary affects on community leadership and collective action.

From Mwanga et al. [47-48]

A participatory intervention in Nigeria controlled an outbreak of schistosomiasis

by treating schoolchildren with MDA, rehabilitating water points and putting up

health signs at the shores of endemic waterways [49]. However anthropological

studies have shown that the banning of fishing and other livelihood activities in

infected waters may not been very effective, and contributes to the stigmatization

of poor communities that depend on fishing [42]. Results of a large-scale 25-year

program to control Schistosoma mansoni in a Brazilian city showed a

reduction from 70% to less than 2% [50]. This utilized an integrated approach

combining mass chemotherapy with improvements in water supplies and sewage

disposal in the context of widespread socioeconomic improvements. Although

subsidized sanitation approaches have been found to be effective in

schistosomiasis control [51], other studies have not shown an impact on infection

rates [52]. Simply providing latrines may not be sufficient, as socio-cultural norms

mediate their use. Participatory approaches to WASH have shown some results,

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and have currently been piloted in some schistosomiasis endemic areas (see

Box 5). However it is important to note that such efforts need to put into place an

ethos of maintaining engineering interventions – without this, WASH

interventions cannot easily be sustained. Furthermore, little guidance is provided

on the potential to scale-up: what would be the costs? The impacts? The

programmatic structure and opportunities for integration? Further research is

needed.

2.6. Chemical Vector Control

Government-funded vector control is central in the global effort to control vectors

and pathogens. Despite calls for integrated vector management (IVM), the

predominant focus of many efforts continues to be sporadic chemical application,

with surveillance and education an irregular component. This includes blanket,

and often reactive, use of larvicide, fogging, indoor residual spaying (IRS) and

aerial spraying. More recent efforts include genetically modified mosquitoes,

which present their own challenges of biological and social implementation, as

many citizens are suspicious of Genetically Modified Organisms (GMOs) [53].

Most studies show major gaps in the operation of vector control programs – in

staffing, capacity, management, funding and community engagement strategies

[23]. Improving these capacities, and the ability to respond to future threats, is a

major element of initiating successful community-based adaptation initiatives to

tackle VBDs.

Two examples, from Burundi and in Latin America, are instructive. Research in

the highlands of Burundi showed that the upper altitude limit for malaria was

increasing and that a longer transmission season was occurring, which

culminated in an epidemic in previously disease-free regions. Operational

research was conducted to assess the effectiveness of using vector control, in

this case IRS, in high-risk lowland (valley) zones to prevent further spread, which

was found to be very effective [54]. This approach used highly technical teams

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and, like many studies on vector interventions, did not take a community-based

approach, nor describe community dynamics that could have influenced

effectiveness. However after the pilot studies funded by the research team, the

vector interventions ceased because of a lack of funding, lack of integration

within the primary healthcare context, and socio-political turmoil in the country.

A separate study in Guatemala, El Salvador, and Honduras explored the

responsiveness of vector control teams between 2008 and 2012 to a novel

community-based surveillance system that reported Triatoma dimidiate infestations, with the idea that government vector control officials would provide

prompt IRS and educational advice on how to manage the infestation [8]. While

community participation was very effective at detecting the vector, the

responsiveness of the health system was lacking. The study explored how to

reinforce vector control outreach by investigating 8 dimensions to implementation

across 12 study areas, including: volume of vector notifications, local geography,

demography, manpower, and managerial approach. They found that consistent

performance monitoring within the local health system was the major pre-

determining factor to effective responsiveness. These examples show the

importance of considering the institutional context of implementation, and the

need to build bridges between different stakeholders to make vector control

efforts more receptive to community approaches. This is especially the case

during the scale-up process (See Box 6).

Box 6: Institutional Evolution of a Community-based Larval Source Reduction Initiative in Urban Tanzania

Larval source management (LSM) campaigns require effective monitoring of larval sites. This requires fine spatial scales in urban landscapes. Participatory learning and mapping can play an important role, and can also assist project staff to be flexible to dynamic and emerging vector patterns. Gaining access to individual household plots in highly dense unplanned settlements is also a major problem that can be addressed by recruiting participants through local committees, who are familiar with the geography and with local residents. The quality of cartographic mapping plays a major role in planning, monitoring and

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managing larvicide application.

In the context of rapid urbanization in Tanzania, a citywide LSM campaign was implemented over a 14-year period in Dar es Salaam, Tanzania. This multi-sectoral community-based initiative used operational research to improve public health governance and sustainable service delivery for vector management. It used Community-Owned Resource Persons (CORPs), appointed through Street Health Committees, to visit every household plot weekly and apply larvicide (as needed) and survey potential mosquito larval habitats. Between 2004 and 2009, the program expanded to cover over 600,000 people. Managing such a project, with large numbers of irregularly paid volunteers, generated a number of frictions at different levels and between partners that had to be negotiated over time. The project found that large numbers of CORPS engaged by local leaders had poor performance and that there may be good reasons to hire smaller cadres that are better paid and incentivized.

One notable aspect of this project was that it ‘built upwards’, from neighborhoods to the city and national scale to influence policy and programming. Overtime, the City Council took greater responsibility for management from the research team, as planning was also decentralized to local administrative structures that enhanced community mobilization as well as funding support from the National Ministry of Health and Social Welfare. Research showed substantial reductions in malaria prevalence and mosquito density as larviciding was scaled-up. The project also successfully transitioned from a research initiative to a nationally-owned pubic health program. The collaboration between independent researchers and implementing partners allowed for a more honest assessment of performance and challenges.

From Chaki et al. [55]

2.7. Access to Biomedical Interventions

Not all attention to VBDs involves vectors, animals and environments but also

diagnosis, treatment and mass chemotherapy approaches that target the

pathogen. Most studies that explore community-based approaches to improved

diagnosis and treatment focus on local illness perceptions, treatment seeking

behavior, the system of healthcare and mass population-wide treatments.

Health messaging efforts aimed at conveying biomedical knowledge to local

communities can become merged into pre-existing ideas and logics, called

syncretic models. Like a game of ‘telephone’, they are interpreted according to

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the receiver’s presuppositions. Appreciating this dynamic can help make health

promoters better adapt messages to local contexts [56]. Certain folk illnesses,

that are considered to be 'malaria' by healthcare professionals, are categorized

very differently by local people. A study on malaria in Tanzania found that homa ya malaria (in Swahili), or malaria fever, did not typically denoted the more

severe forms of the disease, such as cerebral malaria in young children, severe

anemia and malaria in pregnancy [57]. For these conditions, other sources of

treatment are sought, such as from traditional doctors and herbalists.

In the context of malaria elimination and emerging drug resistance in Cambodia,

adherence to treatment is important. Gryseels et al. [58] found three broad

pathways for malaria treatment: i) the public sector; ii) the private sector; and iii)

traditional treatments based on divination and ceremonial sacrifice. Even where

good availability of anti-malarials existed in the public system, single-dose

“cocktails” in the private sector were preferred due to notions of efficacy, local

illness categories and socio-economic barriers that mediated patient choice.

Local categorization and use of health technologies involve processes of transfer

and appropriation embedded within a social context [59]. Barriers to the

treatment of women for genital schistosomiasis in Egypt, for example, include a

general neglect of women’s health, misconceptions about reproduction and

limited access to formal health services for poor women [60]. A study in

Suriname found that harmful non-biomedical substances, such as battery acid,

lead, gasoline and insecticides, were regularly used to treat leishmaniasis [61].

Occupational contexts, such as working in gold and lumber sectors, meant that

patients had access to these substances, while lower education, geographical

distance to treatment centers, fear of injections, notions of masculinity and

associative reasoning linking a ‘cruel disease’ to the need for a ‘cruel treatment’

were major drivers. Lastly, health-seeking behavior can also be influenced by

ethnicity, as found in a study on new diagnostic tests for sleeping sickness in

South Sudan [62].

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Rapid decrease in vector-borne diseases has been reported following the

implementation of well-organized community-based monitoring, training and

support for village health workers [63], especially with the dissemination of Rapid

Diagnostic Tests (RDTs) and arteminisin therapy (see Box 7). Studies have also

assessed the uptake of training modules for rapid diagnostic tests, for example

with private clinics, outreach workers and even teachers [62,64].

The population-wide delivery of chemotherapy continues to be a major

component of the global fight against some VBDs, including mass drug

administration (MDA) of praziquantel for schistosomiasis, and emerging support

for focalized MDA for malaria elimination [65]. Research on MDA delivery

channels of praziquantel has shown that a community-wide approach using

community volunteers has the best coverage, compared to targeting only health

facilities and schools [66]. Research has also shown that compliance with free

treatments can be negatively effected by: a lack of information, rumors and

mistrust, local understandings of disease, the method of drug distribution and

population movement across borders [45]. Education of communities about the

purpose of taking the drug is paramount, but often incompletely done. For

example, after a 7-year campaign that combined MDA with health education in

Senegal, only 30% of the population knew about the symptoms and mode of

transmission, suggesting that education efforts were not being implemented with

adequate attention to the implementation process and community perceptions

[67]. There is a need to engage local leaders to take ownership of mass

treatments by selecting volunteers and organizing the activities [68].

Box 7: Malaria Control in a War Zone: The Case of Burma

Active zones of war and conflict present major challenges for VBD control, and will continue to do so in the future. Large-scale malaria programs are rarely implemented in these contexts, especially as humanitarian agencies scale-back programs when violence erupts. In Eastern Burma, decades of conflict had displaced more than half-a-million people who lived in zones between rebels and government forces. A grassroots NGO operating health clinics and backpack

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teams in these areas implemented a network of village health workers to prevent malaria infection, which was estimated to account for 25% of overall morbidity and 40% mortality. This included training networks of village health teams, working under the guidance of clinic-based teams, so that they could distribute insecticide-treated nets, conduct simple diagnosis and provide malaria treatment. The intervention was scaled-up across more than 50 villages and was found to have reduced malaria infection rates. Regular ‘train-the-trainer’ workshops, held outside the conflict zone, were an important strategy to maintain health worker performance.

From Lee et al. [69]

When outbreaks of disease occur in new areas, communities adapt and change

their perceptions and practices – Nazareth et al. [70] reported on changing

practices after a dengue outbreak on a Portuguese island. But war and conflict

present a different challenging situation for public health agencies (see Box 7).

Humanitarian contexts make it hard to integrate screening and treatment of

VBDs with the health system in areas experiencing epidemics during conflict

(such as malaria in Afghanistan or sleeping sickness in the Democratic Republic

of Congo) is complex since [71-72]. Targeted activities are needed in the

absence of state infrastructure. Furthermore, resilience needs to be built across a

gradient of social space to deal effectively with VBDs in conflict zones and post-

conflict periods, where the transition from humanitarian programs to government

and development agencies is fraught with social and political challenges.

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